U.S. Army Professional Filler System Nursing Personnel: Do They Possess Competency Needed for Deployment?

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1 MILITARY MEDICINE, 171, 2:142, 2006 U.S. Army Professional Filler System Nursing Personnel: Do They Possess Competency Needed for Deployment? Guarantor: MAJ Felecia M. Rivers, ANC USA Contributors: MAJ Felecia M. Rivers, ANC USA*; Dana H. Wertenberger, PhD ; CAPT Katherine Lindgren, USNR The objective of this study was to identify the perceived readiness of U.S. Army Professional Filler System personnel in regard to nursing competency and readiness for deployment. A purposive sample of research participants (N 131) from two military treatment facilities assigned to Great Plains Regional Medical Command responded to an electronic Readiness Estimate and Deployability Index (READI). The READI measures self-reported competencies in six dimensions of nursing readiness. Descriptive statistics and one-way analysis of variance were used to analyze the data. Although the research surveyed three levels of nursing skills (registered nurse, licensed practical nurse, and certified nursing assistant), the study results were noted to be quite parallel across the groups. Significant differences were noted throughout the six dimensions of the READI and between the two military treatment facilities in the dimensions of operational nursing competencies and personal and psychological readiness. Findings support the need for a structured core competency tool to provide succinct focused training to ensure deployment readiness. *U.S. Army Health Clinic, Katterbach, Germany, APO AE, University of Tennessee, School of Nursing, Chattanooga, TN The competency conceptual foundation was previously awarded the Federal Nursing Service Essay Award, Information regarding the pilot study was presented at the Karen A. Rieder Nursing Research Poster Session during the 108th Annual Meeting of the Association of Military Surgeons of the United States, November 11, 2002, Louisville, KY. Information relating to competency skills was presented at the Nursing 2003 Symposium; April 13 16, 2003; Lake Buena Vista, FL; and at the Nursing Research Day, University of Tennessee; April 18, 2003; Chattanooga, TN. This manuscript was received for review in October 2004 and was accepted for publication in February Reprint & Copyright by Association of Military Surgeons of U.S., Introduction s early as the Revolutionary War, nurses have responded A patriotically to care for troops in wartime situations. The need for educated health care providers to function in humanitarian missions, wartime, and military operations other than war (MOOTW) is well documented in the literature. 1 3 Professional Filler System (PROFIS) nursing personnel must maintain competency skills and functions critical to their individual roles in a deployed or field status. These nursing roles include critical care, preoperative/postoperative care, anesthesia care, radiology, laboratory, pharmacy, nursing/personnel management, emergency trauma management, and other diverse medical nursing roles, including the fields of pediatrics and obstetrics/ gynecology. In the past, nursing personnel have relied on clinical experiences in a military treatment facility (MTF) to maintain their competency for deployment status. However, the differences between nursing skills in a MTF and in a deployment hospital have broadened. Nursing personnel now use skills during deployment that are not routinely practiced in a MTF. Several noted differences include specialized care in a fixed facility versus general nursing care in the combat setting, high technology versus low technology in a field environment, automated equipment versus manual equipment, and moderate to high diversity in care scenarios in the combat setting. 4,5 Presently, core competency skills of PROFIS personnel have not been defined. The purpose of this research study was to identify the perceived readiness of U.S. Army PROFIS personnel for deployment with respect to nursing competency skills and to identify skills that were beyond those used routinely in a MTF by using an electronic version of the Readiness Estimate and Deployability Index (READI) and a core competency tool currently used in a MTF, for comparison. Previous Related Works The original READI is a paper-and-pencil questionnaire that measures six dimensions of individual readiness, i.e., (1) clinical nursing competency, (2) operational nursing competency, (3) soldier/survival skills, (4) personnel/physical/psychosocial stress, (5) leadership and administrative support, and (6) group integration and identification. In the development of the READI, subject matter experts in each of the identified areas developed questions for the initial READI survey. Validity for the items was estimated with content validity-testing techniques using eight content experts. The experts rated each individual item on a scale of 1 (low) to 4 (high). The mean ratings were 3.6 for clarity, 3.6 for relevance, and 3.6 for uniqueness. Changes to the questions were made on the basis of the recommendation of the subject matter experts and were incorporated into the initial version of the READI. 5,6 The READI was refined on the basis of results of internal consistency and test-retest reliabilities from a pilot test with a sample of 31 Army nurses. The test-retest reliabilities and internal consistency reliabilities for the six subscales were as follows. The nursing competency scale had 28 items (r 0.71; 0.94). The operational nursing competency scale had six dichotomous unscaled items (r 0.48). The soldier and survival skills scale had 10 items, which demonstrated the strongest psychometric results (r 0.83; 0.91) among all of the scales. The personal/physical/psychosocial scale had eight heterogeneous items (r 0.78; 0.73). The leadership and administrative support scale had four items (r 0.69; 0.83). The group integration and identification scale had three dichotomous items (r 0.69; 0.72). 6 The result of this testing was a revised, 105-item, survey tool that measures self-reports of cognition, affect, perception of psychomotor skills, and physical ability related to the six areas of nursing readiness. The READI was deemed to be a valid reliable tool to be used in the military population. Theoretical Framework and Sampling Frame The model of novice to expert described by Benner 7 equates well with the design of the questions used in the READI. Benner 142

2 Competency of PROFIS Personnel 143 uses a five-tier format (novice, advanced beginner, competent, proficient, and expert) in her model. The READI also encompasses a five-tier format in the design of the questions, ranging from not competent to totally competent. The three domains expressed in the theory of stress resistance described by Flannery 8 adapts appropriately to the individual sections of the READI. The domain of mastery is expressed in the sections of clinical nursing competency, operational nursing competency, soldier and survival skills, personal and physical readiness, and psychosocial readiness. The domain of attachment is demonstrated in the section relating to group integration and identification. Finally, the domain of meaning is portrayed in the section relating to leadership and administrative support. Therefore, there is a logical rationale supported by the theoretical framework described by Flannery. 8 The sample for this study (N 131) included research participants from two of the nine MTFs across the Great Plains Regional Medical Command. Army Nurse Corps officers and their enlisted counterparts who were assigned as PROFIS personnel to a combat support unit in the 1st Medical Brigade were used as subjects. An Army community hospital and an Army medical center were chosen for statistical comparisons of nursing competency and readiness for deployment. The MTFs selected for the study were Darnall Army Community Hospital (Fort Hood, Texas) and William Beaumont Army Medical Center (Fort Bliss, Texas). The initial sampling frame (N 364) consisted of the names and unit addresses of personnel assigned to a PROFIS position in these two locations. Names and unit addresses were requested through points of contact at the individual medical facilities. The sampling frame was considered an adequate representation because it covered 50% of the entire Great Plains Regional Medical Command PROFIS population ( 750 PROFIS personnel). Institutional Review This study was approved and funded by the Tri-Service Nursing Research Program, Uniformed Services University of the Health Sciences (Bethesda, Maryland), the Department of Clinical Investigation, University of Tennessee at Chattanooga (Chattanooga, Tennessee), and the Department of Clinical Investigation of Brooke Army Medical Center (Fort Sam Houston, Texas) and William Beaumont Army Medical Center (Fort Bliss, Texas). Results of a Pilot Test/Retest for the Electronic READI TABLE I PILOT STUDY RELIABILITY CORRELATION (N 9) Survey Subset No. of Items Clinical nursing competency (n 35 items) Strong reliability 20 Medium reliability 12 Weak reliability 3 Operational nursing competencies (n 11 items) Strong reliability 8 Medium reliability 3 Weak reliability 0 Soldier/survival skills (n 11 items) Strong reliability 6 Medium reliability 3 Weak reliability 2 Personal and physical readiness (n 5 items) Strong reliability 5 Medium reliability 0 Weak reliability 0 Psychosocial readiness (n 22 items) Strong reliability 10 Medium reliability 4 Weak reliability 8 Leadership and administrative support (n 5 items) Strong reliability 2 Medium reliability 2 Weak reliability 1 Group integration and identification (n 4 items) Strong reliability 1 Medium reliability 1 Weak reliability 2 To convert the previous paper-and-pencil version of the READI into an electronic version, a pilot test/retest study was conducted. The only changes made to the electronic version of the READI, compared with the paper-and-pencil version, were changes in demographic factors adapted to fit the sample. An initial sample of 25 PROFIS participants assigned to Darnall Army Community Hospital were invited to participate in the pilot study. Nine (36%) of the 25 participants completed the pilot study. Of those participants, five were male and four were female. Six of the individuals were officers (66.7%) and three (33.3%) were enlisted personnel. Five of the nine individuals held a bachelors degree in nursing. A bachelors degree in nursing is required by the active component of the Army to enter the service as an officer and registered nurse. Of the remaining four participants, educational levels ranged from a high school diploma to a masters degree in nursing. Only one individual had been previously deployed in his military occupational specialty/ area of concentration. Two officers had previous enlisted service. All participants had field training within the current year (2002), with an average of 4 days of training. No variance in the demographic data between the test and retest phases was noted. The READI consisted of six nursing subsets. The electronic READI was administered initially and then 2 weeks later. The subsets were analyzed by using Pearson s r statistic for correlation over time and Cronbach s coefficient for internal consistency and reliability. Because of the small sample size, the coefficients are depicted as strong ( ), medium (0.4 TABLE II SUMMARY OF RELIABILITY ANALYSIS Questionnaire Section Electronic Version r Pencil-and-Paper Version r Clinical nursing competency Operational nursing competency Soldier/survival skills Personal and physical readiness Leadership and administrative support Group integration and identification

3 144 Competency of PROFIS Personnel TABLE III DESCRIPTIVE STATISTICS FOR DEMOGRAPHIC VARIABLES No. % Area of concentration/military occupational specialty 66C, psychiatric nurse E, perioperative nurse F, nurse anesthetist H00, medical/surgical nurse H8A, critical care nurse H8E, nurse practitioner H8F, community health nurse HM5, emergency nurse B/91W, medical specialist C/91M6, licensed practical nurse D, surgical technician X, behavioral health technician Other Length of time in service a (years) Level of education Less than bachelors Bachelors in nursing Masters in nursing Age of soldier b (years) a Length of time in service was collapsed for better depiction. b Age of soldier was collapsed into three categories for better depiction. 0.69), and weak ( ). Table I demonstrates the analysis of correlation. A summary of the reliability analysis is provided in Table II. The leadership and administrative support scale is very short, containing only five items. The small sample may account for the low 0.24 reliability coefficient. Although the sample size was small, the paper-and-pencil version of the READI and the electronic version of the READI were deemed to be comparable. Because of the comparability identified in the pilot study, no changes to the survey instrument were recommended. The major study commenced after the pilot study, at the two MTFs. Major Research Study TABLE IV ANOVA FOR CLINICAL NURSING COMPETENCIES BETWEEN MILITARY OCCUPATIONAL SPECIALTIES Source F p Competency Competency Competency Competency Competency a Competency a Competency a Competency Competency Competency a Competency Competency b For all comparisons in this table, the degrees of freedom between groups are 3 and within groups are 127, for a total of 130. a p b p Description of the Major Research Sample One hundred thirty-one participants, of 338 eligible to participate in the research, responded to the survey within the 60-day period, resulting in an overall response rate of 39%. Twentynine of 44 possible participants from Darnall Army Community Hospital completed the survey, resulting in a site response rate of 66%. One hundred two of 294 possible participants from William Beaumont Army Medical Center completed the survey, resulting in a site response rate of 35%. Ninety-one surveys (27%) were completed within the first 30 days, and the remaining 40 (12%) were returned within the 60-day period. Seventy-nine officers (60%) and 52 enlisted personnel (40%) completed the survey. Fifty-seven women (44%) and 74 men (56%) responded. Thirty soldiers (23%) had been previously deployed. Twenty-four (30%) of 79 officers reported previous enlisted time. The number of years of previous enlisted time ranged from 3 years to 15 years, with an average of 7 years. Numerous military occupational specialties were identified for the previous service. However, 91C/91M6 (licensed practical nurse) appeared more often than the other military occupational specialties. Thirty-three research participants indicated they had civilian nursing experience before entering the military. The more commonly mentioned fields were medical/surgical, cardiac, critical care, and emergency/trauma nursing. The average number of years of civilian experience was 5.5 years. Twelve of the 131 participants indicated they had not completed any annual readiness training with a combat support unit. Therefore, these individuals had not met annual readiness requirements for their PROFIS status and possible deployment. For those who completed annual training, the most frequently reported number of days of readiness training was 5 days. Other descriptive data are depicted in Table III. Descriptive Findings The first of two research questions for this study was as follows: are there differences in perceived competency skills required for deployment in the combat support arena among PROFIS personnel assigned to the fixed facility? The means and SDs were calculated from responses on a 5-point rating scale to answer the research question. The numbers of items varied by topic and section. One-way analysis of variance (ANOVA) was used to test for statistical significance. The data were statistically analyzed at a confidence interval of 95%. Because this research study surveyed both enlisted and officer PROFIS personnel, the data are presented in group format, as 66XXX (registered nurse), 91C/ 91M6 (licensed practical nurse), and a third group composed of 91D (mental health specialist), 91X (operating room specialist), and other military occupational specialties. In the 91B/91W (certified nursing assistant) group, only five individuals completed the survey. Therefore, the results for this group might not be a fair representation of their skill levels; results are not displayed in the panoramic graph but are included in the tables

4 Competency of PROFIS Personnel and ANOVAs for review. Significant differences were noted between the groups throughout the six dimensions of the READI. The READI uses a 5-point scale, as follows: 1, not competent; 2, slightly competent; 3, somewhat competent; 4, competent; 5, totally competent. After review of the data analysis, we thought the results of the research could be more clearly displayed if the 5-point scale was collapsed into three categories, i.e., not competent, moderately competent, and totally competent. Table IV provides an ANOVA of a portion of the clinical nursing competency results. Figure 1 and Tables V to VIII illustrate the means and SDs for the different subsets. Clinical Nursing Competency Participants reported low levels of competency for more than one-half of the clinical competency skills, including caring for patients in hemorrhagic shock, implementing documentation in a field environment, reconstituting medications, performing in a code situation, implementing Advanced Cardiac Life Support protocols without a physician, caring for life-threatening injuries, and implementing triage categories. Moderate to high levels of competency were noted in areas such as following standing orders, responding to code situations, and deciding who would be treated first in a shock scenario. None of the participants reported the highest level of competency in this category. Operational Nursing Competency All groups reported moderately high competency in field sanitation and hygiene and deployable medical systems proficiency. Slightly low competency means were reported for evacuation procedures, reporting unlawful acts, and echelon of care. Very low means were noted for use of the 12-lead electrocardiograph and the suction apparatus. The same results were noted in previous studies Soldier/Survival Skills The results were fairly consistent across the three groups, with means varying from 2.25 to 3.43 for perceived competency in soldier and survival skills. The lowest item score among all three groups was for competency in the ability to resist the enemy if captured. The highest rated item was the ability to navigate using a map and a compass. The enlisted soldiers reported greater competency in using the Army communications equipment than did the officers. All groups rated moderately in the ability to defend themselves and their patients and in using the M40 mask and protective gear during a nuclear/ biological/chemical attack. Personal/Physical/Psychosocial Readiness The research study results indicated that PROFIS personnel were moderately to mostly ready in all categories. Very few personnel were noted to have physical restrictions that limited them during deployments, and all personnel had moderate scores on their physical training tests. All had met their dental examination requirements. The research participants had high scores in rating any pending legal matters, having a care plan if applicable, and family support during deployment. All participants indicated low to moderate scores relating to stress at home or work. This study indicated low levels of readiness relating to death, carnage, one s own death, battle fatigue, and weather extremes, compared with previous studies. 6 The research participants did indicate a moderately high level of readiness for long work hours. Leadership and Administrative Support PROFIS personnel indicated a low level of competency regarding perceived leader concerns. Also, they indicated a low level of competency in the ability of their first-line deployment supervisors to keep them informed. The perceived feeling of the inability of leaders to keep troops informed was noted in previous research. 6 Group Integration and Identification Self-reported ratings for readiness to adjust to crowded/ mixed gender sleeping quarters were moderately high. This study indicated moderate readiness levels in familiarity with the deployment unit s mission, vision, and values. The number of days trained with the deployment unit was rated at a low level of readiness. The number of days spent in the field with their units in the past year varied from 1 day (12.9%) to 5 days (33.5%). Previous research reflected high levels of readiness in the ability to adjust to crowed/mixed gender sleeping arrangements. Some of the research participants (57.1%) also reported a greater number of days (7 days) spent training with their deploying unit. 6 The second research question that was asked was as follows: are there differences in perceived competency levels among PROFIS personnel assigned to various fixed facilities? Two dif- Fig. 1. Panoramic display depicting READI profiles and statistical comparison of active duty nurses, 91M6, 91W, and all other military occupational specialties.

5 146 Competency of PROFIS Personnel TABLE V DESCRIPTIVE STATISTICS FOR CLINICAL NURSING COMPETENCIES AND OPERATIONAL NURSING COMPETENCIES 66XXX (n 79) 91C/91M6 (n 14) READI Scores 91B/91W (n 5) All Others (n 33) Competency in Mean SD Mean SD Mean SD Mean SD Clinical nursing competency 1. Different types of shock Caring for hemorrhagic shock Correct response to shock scenario Documenting in field environment Last time provided direct patient care Types of triage experience IV drip calculations Last time reconstituted, calculated, administered IV medications 9. Instituting standing orders Code/emergency situation Calculating body surface area for burn patient 12. Deciding which patient is seen first Performing ACLS protocols Caring for life-threatening injuries IV skills Describing life saving principals Assessing multiple-trauma patient Care of NBC patient Care of ballistic missile injuries Recognizing tension pneumothorax Fluid replacement for burn patients Universal blood donor protocol Disease, nonbattle injuries Use of field ventilator Airway management Implementing triage categories Assuming clinical team leadership Caring for refugees Pre-partum/postpartum care Field infection control Orthopedic nursing Neurological nursing Identifying components of physical examination 34. Listing examination techniques to perform physical examination 35. Performing nursing assessment and interpreting abnormal findings Operational nursing competency 1. Obtaining 12-lead EKG by scenario Working with suction apparatus Knowledge of recharge time for battery pack 4. Answer for suction power in field hospital 5. Answer for power in evacuation vehicles Answer for power for patient on litter Evacuation procedures Echelon of care Reporting unlawful act or conduct Field sanitation and hygiene DEPMEDS setup Means and SD were calculated from responses on a 5-point rating scale. DEPMEDS, deployable medical systems; IV, intravenous; ACLS, Advanced Cardiac Life Support; EKG, electrocardiogram; NBC, nuclear, biological, chemical.

6 Competency of PROFIS Personnel 147 TABLE VI DESCRIPTIVE STATISTICS FOR SOLDIER/SURVIVAL SKILLS AND PERSONAL/PHYSICAL READINESS READI Scores 91C/91M6 91B/91W All Others 66XXX (n 79) (n 14) (n 5) (n 33) Competency in Mean SD Mean SD Mean SD Mean SD Soldier/survival skills 1. Familiarity with M-16 rifle Familiarity with 9-mm pistol Ability to defend self and patients Protection of self with mask/mopp gear Navigation with map and compass Maintaining weapon in working order Performing in adverse conditions Decontaminating self/patient using decontamination equipment 9. Familiarity with status under Geneva Convention Ability to resist enemy if captured Familiarity with Army communications equipment Personal/physical readiness 1. Last APFT score How long since last dental examination Has family care plan if indicated Has physical profile or not Profile prevents deployment Means and SD were calculated from responses on a 5-point rating scale. MOPP, mission-oriented protective posture; APFT, Army Physical Fitness Test. TABLE VII DESCRIPTIVE STATISTICS FOR PSYCHOSOCIAL READINESS READI Scores 91C/91M6 All Others 66XXX (n 79) (n 14) 91B/91W (n 5) (n 33) Competency in Mean SD Mean SD Mean SD Mean SD Psychosocial Readiness 1. Quality of current family support system Same support system available if deployed Separation 6 months from family Family s response to separation Having a current will Having a current power of attorney Any pending legal matters Current working relationship with coworkers in deployment unit 9. Overall feeling of last deployment Amount of current stress at work Amount of current stress in family Amount of current stress with finances Amount of current stress in other areas How to access emotional support during deployment 15. How to access mental health services while deployed 16. Preparation for death, dying, and carnage Preparation for own death Preparation to deal with battle stress Preparation to deal with weather extremes Preparation to work long hours Preparation to deal with lack of privacy Means and SD were calculated from responses on a 5-point rating scale.

7 148 Competency of PROFIS Personnel TABLE VIII DESCRIPTIVE STATISTICS FOR LEADERSHIP/ADMINISTRATIVE SUPPORT AND GROUP INTEGRATION/IDENTIFICATION Competency in Mean SD Mean SD Mean SD Mean SD Leadership/administrative support 1. Understands set-up, functions, and command structure of TOE unit Competent family care plan will work if deployed if single parent or dual military Rate deployment unit s first-line leaders knowledge and concern for soldiers Rate deployment unit s first-line acceptance of responsibility for tough training Rate deployment unit s first-line leader s ability to keep you informed Group integration and identification 1. Rate ability to adjust to crowded mixed sleeping quarters Number of days trained with deployment unit in past 12 months Familiarity with deployment unit s mission, vision, and values Familiarity with role/duty position in deployment unit Means and SD were calculated from responses on a 5-point rating scale. TOE, troops, organization, and equipment. ferent types of MTFs were chosen to test this research question. One facility is considered a community hospital, whereas the other facility is classified as a medical center. An Army community hospital offers complex, resource-intensive secondary care (e.g., inpatient care, surgery under general anesthesia) at a major post, usually 50 to 150 beds. 9 An Army medical center offers tertiary care (sophisticated diagnosis/treatment of any ailment) as well as primary and secondary care. Medical centers have more sophisticated equipment and more specialized staff and offer wider arrays of specialty care. 9 The means and SDs were calculated from responses on a 5-point rating scale to answer the research question. The numbers of items varied by topic and section. One-way ANOVA was used to test for statistical significance. The data were statistically analyzed at a confidence interval of 95%. The medical center reported slightly higher scores in clinical nursing competency, operational nursing competency, and psychosocial readiness. Table IX illustrates the statistical data. Because the facility is a large medial center with a trauma center, it could be assumed that nursing personal would experience a greater diversity of patient scenarios. This could account for the higher levels of perceived competency skills. Data analysis indicated that there were differences in perceived competency levels among PROFIS personnel assigned to TABLE IX ANOVA BY COMPETENCY SECTION FOR DIFFERENT FACILITIES Source F p Clinical nursing competency Operational nursing competency a Soldier/survival skills Personal and physical readiness Psychosocial readiness b Leadership and administrative support Group integration and identification For all comparisons in this table, the degrees of freedom between groups were 3 and within groups were 127, for a total of 130. a p b p XXX (n 79) READI Scores 91C/91M6 (n 14) various fixed facilities. The differences may result from the training received at the respective medical facilities, previous deployments, or skills learned through personal experiences. Discussion Overall, the data in this study illustrated a difference in perceived competency skills, compared with previous studies. The means within the six dimensions were lower in this research than in previous studies using the READI. Participants reported low competency for more than one-half of the clinical competency skills, including caring for patients in hemorrhagic shock, implementing documentation in a field environment, reconstituting medications, performing in a code situation, implementing Advanced Cardiac Life Support protocols without a physician, caring for life-threatening injuries, and implementing triage categories. In operational nursing competencies, the participants indicated they had a low level of competency in obtaining a 12-lead electrocardiogram and low to moderate competency skills in deployable medical systems setup. The participants reported low readiness for dealing with death, dying, and carnage. Most thought that they had a low to moderate ability to adjust to crowded/mixed gender sleeping quarters and that they did not have enough opportunity to train with their deployment units. Based on the results of the study, these groups of PROFIS personnel tend to project a perceived feeling of not having the appropriate competency skills needed for deployment. These results support previous research findings regarding medical personal and deployments. As military personnel prepare for possible deployment, in view of the present world situation, these perceived feelings could greatly affect mission readiness. Family separation and the unknown greatly influence military deployments. Without the necessary confidence in their nursing skills, individuals could possibly experience even greater levels of stress and discord during deployments, which could affect the quality of care provided. Conclusions 91B/91W (n 5) All Others (n 33) The purpose of the study was to identify the perceived readiness of U.S. Army PROFIS personnel in the Great Plains Re-

8 Competency of PROFIS Personnel gional Command regarding nursing competency and readiness for deployment during combat missions or MOOTW. Two different types of MTFs were chosen to discern a perceived difference in competency skills based on the type and size of the facility. Historical events might have had an impact on the study results. By the completion of data collection, military nursing personnel were again on a heightened state of alert because of a possible conflict with Iraq. Three areas continue to affect preparation for deployment to combat or MOOTW, namely, competency, military readiness, and psychosocial issues. Of the three, competency continues to be documented as a priority for nursing personnel. Military competency includes the ideas of technical proficiency, ability to use nursing skills with field equipment, physical assessment skills, clinical decision acumen, and trauma/ triage skills. 5 Moreover, competency is related to flexibility to and the ability to function in nontraditional roles. In a combat environment, clinical competency is seen as part of three areas, i.e., (1) military specialty-related skills, (2) military-unique skills, beyond what is normally done in the workplace, and (3) trauma intervention capability. 5 Other clinical competencies used in combat include increasing autonomy, implementing orders without a physician, triaging, improvising with a shortage of supplies, using/trusting one s senses during assessment without the benefit of high-technology equipment, and caring for a greater diversity of patients in a harsh setting. 4,10 12 Nursing personnel must be trained to function efficiently for the next military deployment. If medical personnel are not trained effectively, then many will die as lessons are relearned. 13 Army nursing personnel are at risk of being unprepared without a conceptual model to guide professional practice and training. Individual readiness must be a priority for all nursing personnel, because nurses must sustain the health of soldiers to meet deployment missions. Readiness is fundamental to army nursing readiness for deployment, readiness for the future of health care. 14 As military nursing personnel continue to deploy during times of combat or during MOOTW, providing care in strange, possibly dangerous environments, they must be trained to meet the diversity of injuries among patients they may encounter. This research and that of previous studies using the READI support the need for a core competency tool to augment the READI. Future research should focus on the development and piloting of a core competency tool for PROFIS nursing personnel dispersed worldwide. Acknowledgments This research was funded by Grant MDA TS04 (N02-018) from the Uniformed Services University Tri-Service Nursing Research Program, administered through the grant office of the University of Tennessee at Chattanooga. References Ulmer BC: Army Nurse Corps celebrates 100th anniversary. AORN 1991; 73: 8 10, 12, Palmer P: Wars leave indelible marks on the nursing profession. AORN 1991; 53: Kalish P, Kalish B: Untrained but undaunted: the women nurses of the Blue and the Gray. Nurs Forum 1976; 15: Zadinsky J: The Readiness Training Program for Nursing Personnel. AMEDD-MD 2401 Training Support Package. Fort Sam Houston, TX, U.S. Army Medical Department Center and School, Reineck C: The Federal Nursing Service Award: individual readiness in nursing. Milit Med 1999; 164: Reineck C, Finstuen K, Connelly LM, Murdock P: Army nurse readiness instrument: psychometric evaluation and field administration. Milit Med 2001; 166: Benner P: From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Upper Saddle River, NJ, Prentice, Flannery RB Jr: Becoming Stress-Resistant through the Project SMART Program. New York, Crossroads Publishing, Army Medical Department: Medical facilities. Available at accessed February 10, Norman E: A study of female military nurses in Vietnam during the war years of J Nurs Hist 1986; 2: Norman E: Women at War: The Story of Fifty Military Nurses Who Served in Vietnam. Philadelphia, University of Pennsylvania Press, Stanton-Bandiero MP: Shared meanings for military nurse veterans: follow up survey of nurse veterans from WWII, Korea, Vietnam, and Operation Desert Storm. J N Y State Nurses Assoc 1998; 29: Sebesta D: Experience as the chief of surgery at the 67th Evacuation Hospital, Republic of Vietnam, 1968 to Milit Med 1990; 155: Kennedy T, Hill E, Adams N, Jennings B: A conceptual model of Army nursing practice. Nurs Manage 1996; 27: 33 6.